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What If My Baby Is Breech?

By around week 32 of pregnancy, two-thirds of babies have adopted the normal head-down position in the uterus (womb).

This is also known as the cephalic or vertex position. By 36 weeks of pregnancy, 95% have adopted this head-first position. The reason for this is that the bottom and legs are bigger than the head, so they occupy the top of the womb where there is more space. Although the majority of babies are born with their head coming first, there may be a situation where your baby is lying in an unusual or awkward position.

Malpresentation occurs when the baby is not in the cephalic position. These are most commonly breech (bottom first), but the baby may also be lying transversely (across the uterus). Malpresentation can make a vaginal delivery difficult or even impossible.

Types of malpresentation

Breech: where the feet or buttocks face downwards and would be delivered first. Around 2-4% of babies presents in the breech position at the end of pregnancy and this is the most common type of malpresentation.

Face: where the face, rather than the top of the head, will appear first during delivery. Such babies can sometimes be delivered vaginally.

Oblique: where the baby lies at an angle across the uterus. This requires delivery by caesarean section if the baby can't be moved into a longitudinal position

Transverse: where the baby lies transversely (horizontally) across the uterus, and a shoulder will appear first during delivery; additionally, the umbilical cord can fall into the vagina and cause fetal distress. Babies who remain in a transverse or oblique position are almost always delivered by caesarean section.

What happens next?

If your baby is lying in a breech position, then your doctor may wait to see if your baby turns naturally to a head-down position. If your baby has not turned by 36 weeks, then your doctor will usually recommend an external cephalic version (ECV), in which your baby is gently turned by the doctor's hands on your stomach into a cephalic presentation. ECV is carried out to help to change the presentation of your baby from breech to a head-down position.

The obstetrician will usually check the position and condition of your baby on ultrasound first and then gently, with his/her hands on your tummy, rotate the baby around 90 degrees so that the baby lies transversely, before letting go, so that the baby will the adopt a head-first position. After trying, the doctor will check the baby's heart rate, and his/her position.

Will it work?

ECV only works about half the time and is more likely to work in women who have already had babies. Where it does work, your baby is likely to stay head first and you will have a very good chance then of having an uncomplicated birth. ECV is usually only done after 36 weeks, and there will be some babies who are not suitable for turning, such as twins, or where the mother has had a previous caesarean.

Can I give birth naturally?

If ECV fails, then your baby is likely to remain as a breech until the time of birth. You will need to discuss with your doctor whether or not it is still safe for you to give birth vaginally with a breech. In some cases, a caesarean will definitely be recommended. Such cases include where the baby is big, or presenting by the feet or cord. In other cases, you may be offered a choice between vaginal delivery and elective caesarean section.

The main risks of a vaginal breech birth are an increased risk of needing an emergency caesarean section in labour (around one in three), and a small risk of damage to the baby (around one in 500) from the breech birth. Although you may still be allowed to undergo normal delivery with a breech baby, a vaginal breech birth can be more complicated than a head-first delivery. For a breech delivery, it is common practice to give an epidural in case the head gets stuck and the doctor needs to manipulate or free the baby to deliver him/her.

Are there any risks?

A transverse lie may correct itself, changing to cephalic or breech in late pregnancy, either with time, or when the mother goes into labour. If the baby stays transverse, it cannot be born vaginally and a caesarean is required for safety. One problem when the baby lies transversely is that, rarely, the cord may come down into the vagina when the waters break, as the head or bottom (which normally blocks the pelvic outlet) is not there to stop it.

This is called a cord prolapse, and requires urgent action by the obstetrician to deliver the baby immediately and safely. This is usually by caesarean section. This is why women with a transverse lie in late pregnancy are often kept in hospital until they go into labour, or the baby no longer lies transversely.

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